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80 Cards in this Set
- Front
- Back
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What is the primary Sx of Ischemic Heart Disease?
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Angina Pectoris
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Types of Angina Pectoris?
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Classic (stable, exertional)
Variant (vasospastic) |
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Etiology of Classic Angina Pectoris?
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Coronary Occlusion (atherosclerosis)
Endothelial Dysfunction (constriction) |
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How do you achieve major results with Rx of Classic Angina Pectoris?
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Decrease O2 Demand
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When does Variant Angina Pectoris typically occur?
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while @ rest
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How do you achieve major results with Rx of Variant Angina Pectoris?
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Increase O2 supply
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What is another, more serious type of Angina?
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Unstable AP
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Why is Unstable AP more serious?
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It involves atherosclerosis AND vasospasm
Unpredictable frequency, duration, and type of pain Occurs at Rest Can form clots-->MI |
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General Rx for Unstable AP?
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Antiplatelet, anti-coagulant Therapy
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What is Silent Ischemia?
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No overt Sx's but there is still ischemia
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General Rx for AP
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Treat Underlying Conditions
Vascular Interventions Drugs |
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What are some underlying conditions that can precipitate AP?
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HTN
Anemia Fatty HF Arrhythmias Anxiety Smoking |
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What are a couple vascular interventions?
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Stenting
By-Passes |
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Goals of AP Rx?
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Stop Attacks
Increase Exercise Tolerance Dec O2 Demand Inc O2 Supply |
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How can you Decrease O2 Demand
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Dec HR
Dec Contractility Alter Pre-Afterload Decrease Ventricular Wall Stress |
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How do you Increase O2 Supply?
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Vasodilators
PTCA By-pass surgery |
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Different modes of Drug Rx of Angina Pectoris?
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Dec HR
Dec Preload Dec Afterload Coronary Vasodilation Dec Contractility |
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Drug for Dec HR?
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Beta Blockers
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Drug for Dec Preload?
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Nitrates
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Drug for Dec Afterload?
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Vasodilators
Ca Antatgonists (nitrates) |
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Drugs for Coronary Vasodilation?
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Nitrates
Ca Antagonists |
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Drug for Dec Contractility?
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Beta Blockers
Ca Antagonists |
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What is the prototypic nitrate?
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Nitroglycerin
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Ways to administer NO?
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Sublingual tablets/sprays
Slow Release Oral/Buccal Forms Transdermal Patches IV |
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Nitrogylcerin MOA in vessel walls?
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Inc cGMP-->
Decreased Ca entry into myocytes--> Dec Contractions--> Relaxation |
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Different Actions of Nitrogylcerin?
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Dec Vasospasm
Dec TPR/Preload Dec Platelet Agregation Peripheral Venous Dilation Dec Extravascular Compression (subendocardial vessels) |
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SE's and Complications w/ Nitrogylcerin?
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-Baroreceptors respond to low BP w/ reflex tachycardia and myocardial contractility
-Tolerance develops rapidly -Methemoglobin development-->cyanosis, hypoxia, death |
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What can stop the Reflex Tachycardia?
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Beta Blockers
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Acute (but transient) SE's of Nitrogylcerin
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Throbbing HA (bad if inc ICP)
Orthostatic Hypotension |
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When do you see methemoglobin toxicity w/ Nitrogylcerin?
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When patient already has a high exposure to Nitrates in environment
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Key Drug Interaction w/ Nitrates?
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PDE 5 Inhibitors
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What are PDE 5 Inhibitors used for?
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ED
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What's the big deal about PDE 5 inhibitors and Nitrogylcerin?
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PDE 5 is responsible for breaking down Nitrogylcerin. If there isn't any, there is prolonged and increased vasodilation which can -->life threatening hypotension
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2 other important Organic Nitrates?
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Isosorbide dinitrate
Isosorbide-5-mononitrate |
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Benefits of Isosorbide dinitrate?
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Less 1st pass metabolism
Extended action oral prep (12hr) |
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Benefits of Isosorbide-5-mononitrate?
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Tabelts/Sustained relief forms
Longer 1/2 life than iso dinitrate No 1st pass metabolism |
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3 classes of L-Type Ca Channel Blockers (CCBs)
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Dihydropyridines
Phenylalkylamines Benzothiazepines |
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Examples of Dihydropyridines?
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Nifedipine
Amlodipine |
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Pharmacokinetics for Nifedipine?
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Onset in 5-20 minutes Oral
1st pass liver metabolism extensive Plasma Protein Binding (drug interactions) |
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Effects of Nifedipine?
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Arteriolar Vasodilator (mostly)
Few cardio-depressant effects |
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Why aren't Dihydropyridines as good as a lot of other drugs for stable angina?
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B/c stable angina is due to atherosclerosis and vasodilation doesn't help much
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SE's of Nifedipine?
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Hypotension
Reflex Tachycardia Flushing HA Peripheral Edema |
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Amlodipine Pharmacokinetics?
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Slower absorption/prolonged action-->dec reflex tachycardia
Half Life = 35-50 hrs Coronary and Peripheral Vasodilation |
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SE's for Amlodipine?
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Reduced Reflex Tachycardia
No cardiodepression |
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Examples of Phenylakylamines?
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Verapamil
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VERAPAMIL
Pharmacokinetics (onset, administration, metabolism) |
Oral onset in 30 min
IV onset in 1-2 min 70% eliminated by kidney, 15% by GI |
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VERAPAMIL
Main Effect |
Cardiac Suppression
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VERAPAMIL
Mechanism of Action? |
Direct Slowing of Cardiac Conduction (slows HR, no reflex tach)
Peripheral Vasodilation (not much) Dec Cardiac Inotropy Dec Afterload |
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What does VERAPAMIL do to Variant Angina?
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Inhibits Coronary Vasospasm
Inc O2 Delivery |
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SE's of VERAPAMIL
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No Tachycardia
Myocardial Depression-->bradycardia, transient asystole, arrhythmia Development/Worsening HF |
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Example of a Benzothiazepine?
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Diltiazem
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Onset and Metabolism of DILTIAZEM
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Oral - 30 min
IV < 3 min Hepatic Metabolism |
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DILTIAZEM and vasodilation and cardio-suppression?
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Mid range guy
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DILTIAZEM
MOA? |
Dilates epicardial/subendocardial arteries
Inhibits coronary vasospasm Mid level peripheral vasodilation and cardiac suppression |
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DILTIAZEM
SE's |
Nausea
Swelling Edema Arrhythmia (lots) |
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DILTIAZEM
contraindication? |
Ventricular Dysfunction
Conduction Disturbances Systolic BP <90 |
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MOA for Beta Blockers in Angina?
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Slow HR
Dec Contractility Dec BP |
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Common use of Beta Blockers in Angina?
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Prophylactic
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Who are Beta Blockers a good partner along with?
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Sustained Release Nitrates
(dec nitrate tachycardia) |
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Examples of Beta Blockers for Angina?
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Metoprolol
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Onset and Metabolism of Metoprolol?
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Oral 1-3 hrs
Sustained release preps available 1st pass metabolism by CYP2D6 |
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Kicker with CYP2D6?
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can have genetic variations that make it dysfunctional
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Which receptor does Metoprolol target?
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Beta-1
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Metoprolol's Mechanisms?
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Dec Contractility
Dec HR Prolong Diastolic Interval (better perfusion) Anti-HTN (chronic Rx) Antioxidant |
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How is metoprolol anti-HTN?
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Dec Afterload
Dec Renin/SNS activity |
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SE's of Metoprolol?
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Cardiac Depression
CNS: sedation, insomnia, depression Undesirable Beta-2 blocking |
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What happens when metoprolol block Beta 2's?
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Worsen Asthma and other reactive airway issues
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How can you reverse Beta blockers in emergencies?
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Glucagon
Isoproterenol |
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Bad drug interaction of metoprolol?
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Can cause cardiodepression when combo'd w/ Ca Channel Blockers
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How to discontinue?
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Slowly otherwise you get rebound SNS activity
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Indication for Ranolazine?
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Refractory Chronic Angina
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Ranolazine MOA?
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Inhibits late Na current-->
Dec intracellular Ca also inhibits FA oxidation-->glucose utilization |
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Contraindications of Ranolazine?
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Prolonged QT interval
Quinidine, dofetilide, sotalol CYP450 3A inhibitors (ketoconazole, verapamil, diltiazem) Hepato/Renal Disease |
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Special Types of Stents?
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Drug Eluting Stents
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Specific Drug Eluting Stents?
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Paclitaxel (Taxol)
Sirolimus (rapamycin |
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MOA for Paclitaxel?
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Forms stable, non functional microtubules
Prevents Smooth Musc prolif |
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Mech for Sirolimus (rapamycin)
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Inhibits mTor (cell cycle kinase)
Prevents Smooth Musc Prolif Anti-Infl |
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Rx progression for Stable Angina?
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Nitrates
Aspirin + Beta Blockers Ca Channel Blockers + Beta Blockers ACE-I if LV dysfunction |
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Rx for Variant Angina?
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Usually Nitrates + Ca Channel Blockers
Beta Blockers alone no good Combo BB's w/ nitrates/CCB's only in refractory cases |
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Rx for Unstable Angina?
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Aspirin/Anti-platelet/Anti-Coag
Nitrates BB w/ Nitrates CCB if refractory Dihydropyridines are worthless |
